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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606747
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:33:44 PM

Document Has Been Signed on 11/24/2021 12:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAN DIMAS ADVENTIST HOME CAREFACILITY NUMBER:
197606747
ADMINISTRATOR:JASAIEL DE LEONFACILITY TYPE:
740
ADDRESS:1136 N. SAN DIMAS AVENUETELEPHONE:
(909) 971-9769
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 5DATE:
11/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Caregiver, Mark SantiagoTIME COMPLETED:
12:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Mark Santiago and explained the reason for the visit. The Administrator is currently out of town and unavailable. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 113.8 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. The facility does not have any cameras inside or outside the home.

LPA reviewed all resident files. Resident #1 (R1) and Resident #2 (R2) were observed using half-length bed rails on their beds. R1's and R2's files were reviewed and did not contain physician's orders for bed rails as required. R1 is on hospice and physician's report indicates R1 is bedridden. Facility does not have an approved bedridden plan of operation on file. LPA reviewed staff files. Files were complete including but not limited to first aid certificates, health screenings, proof of training, and proof of fingerprint clearance. LPA reviewed all residents' medications. Medications are documented properly and given as prescribed. At the time that LPA entered the facility, staff did not assess or take LPA's temperature. Also a visitor was seen entering the facility and staff did not assess the visitor or require the visitor to sign-in as required per COVID-19 procedures.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to caregiver.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 11/24/2021 12:33 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/24/2021 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Staff should conduct routine symptom screening (+/- temperature and symptom check) at entry for all staff, residents, and visitors. Staff did not assess LPA or visitor observed entering the facility.
POC Due Date: 12/08/2021
Plan of Correction
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Staff will be trained on these COVID-19 procedures. Proof of training will be submitted by 12/8/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/24/2021 12:33 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/24/2021 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility should have a sign-in policy for all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing). Facility did not require LPA or another visitor to sign-in at the time of the visit.
POC Due Date: 12/08/2021
Plan of Correction
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Staff will be trained on these COVID-19 procedures. Proof of training will be submitted by 12/8/21.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/24/2021 12:33 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/24/2021 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(1)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed, the licensee did not comply with the section cited above in 1 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care. Resident #1's (R1) physician's report indicates R1 is bedridden. R1 was also observed and was not able to reposition in bed. R1 is currently on hospice. Facility does not have a bedridden plan of operation and does not have the required training on file for staff regarding bedridden residents.
POC Due Date: 12/08/2021
Plan of Correction
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Facility will submit a bedridden plan of operation and will submit plan for approval by 12/8/21. Staff were provided with a copy of Title 22 Regulations regarding bedridden residents.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and records reviewed, the licensee did not comply with the section cited above in 2 out of 5 resident records which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) and Resident #2 (R2) were observed having half-length bed rails on their beds. Resident files were reviewed and R1 and R2 did not have physician's orders for the postural supports.
POC Due Date: 12/08/2021
Plan of Correction
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Facility will obtain physician's orders for bed rails for both residents. Physician's orders will be submitted to the department for review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2021


LIC809 (FAS) - (06/04)
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